Heavy drinkers should be denied liver transplants

There are not many things that should be said about our model. Most countries in the world are currently using some principle according to which they distribute livers for transplantation. It is mainly a queue-based system. We are proposing not to include alcoholics in these queues.

We acknowledge that sometimes it may be complicated to draw a line between alcoholics and other human beings. However, we believe that for alcoholism, as any other disease, there is a set of symptoms that professional doctors can use to decide whether a person is an alcoholic or not. We would urge the honourable opposition to focus on the core points in this debate.

We believe that public policy regarding a distribution of a scarce resource should always be guided by two most important principles. Firstly, the distribution should be as efficient as possible; secondly, the distribution should comply with the conception of fairness and justice. These aims tend to be somewhat contradictory, but we believe that the model that we have proposed reconciles both of these ideals.

So our burden of proof in this debate is to show why our model is efficient and why it achieves the fair distribution of resources. In this argument we will show why it is efficient.

In general, we believe that governments always have a mandate to be utilitarian, i.e. strive for biggest possible good in the society. Why is that? Well, state ideally is a social construct designed to achieve the biggest possible good/happiness/utility etc. It would be a bit awkward if people would not require the government to do that. Of course, these positive aims can also include ethical considerations or other things – the utilitarian government framework does not require us to become ruthless pleasure seekers.

Of course, we can all agree that there are some problems with the utilitarian doctrine. For instance, it usually is hard to agree on what is the “good” we should strive for. However, we believe that our moral intuition can help us in this task. For instance, most of us who do not have psychopathic tendencies would agree that death is preferrable to non-death. Most of us would also agree that one death is preferrable to two deaths of human beings. We strongly believe that these beliefs have universal moral value and always should be encorporated in government policy.

We will be operating under these reasonable assumptions about what is good and what is not in the following argument.

We have no doubts that giving livers to alcoholics is a waste of resources and prevents us from saving lives of other citizens. Why is that so? Well, we believe that is clear that if a liver is given to an alcoholic and he is often not saved anyway (as we shall see in a moment), we have wasted an organ that could be used to save another, equally valuable life instead.

So why is our model the best way to distribute livers efficiently? There are three mechanisms through which this efficiency is achieved:

(1) The chances of a successful transplantation are lower for alcoholics

A very important factor influencing the success of any transplantation is the way the body of the patient responds to the new organ. It is crucial that no complications arise; otherwise, the procedure is likely to fail.

Unsurprisingly, these risks are higher for chronic alcoholics. Firstly, alcoholics usually have other alcohol-related disorders, like chronic pancreatitis [[http://digestive.niddk.nih.gov/ddiseases/pubs/pancreatitis/]] and cerebral atrophy [[http://www.alcohol-drug.com/neuropsych.htm]]. Secondly, alcoholics very often have nutritional deficiencies [[http://www.about-alcohol-facts.com/Alcohol_Nutrition_Facts.html]] that strongly complicate the transplant acceptance process.

All of these aspects show that there is a significantly bigger chance of a failed operation and recovery process, thus wasting organs that could be used to save other patients.

(2) There is a significant risk of a relapse of alcoholism, thus ruining the implant.

It should come as no surprise that alcoholism is a very complicated disease to deal with. Using alcohol for a long time creates both a psychological and physiological addiction, and it is very complicated to supress the desire to drink.

We believe that there is a significant risk that these patients will continue drinking after the procedure. Even though there is a six-month sobriety period before any liver transplantation, empirical evidence shows that heavy drinkers go back to their old ways and start drinking again [[http://psy.psychiatryonline.org/cgi/content/abstract/42/1/55]]. Why is this likely to fail the procedure?

Firstly, all receivers of a liver always face a high chance of getting an infection, so they have to take immunosuppressant drugs that strengthen their immune system. Using alcohol is extremely detrimental for the immune system. It also negatively effects the impact of the immunosuppressant drugs. [[http://www.guardian.co.uk/science/2005/oct/05/drugsandalcohol.medicineandhealth]] Thus alcoholics effectively open themselves up for infections and often ruin the transplant.

Secondly, if alcoholics start drinking again, it can once again lead to the alcoholic liver disease and other alcohol-related disorders. This would once again put the burden on the health care system and maybe even generate the necessity for another transplant.

On the other hand, if we reject giving transplants to alcoholics, they could be assigned to patients with much bigger probability of survival after the operation, thus achieving distributional eficiency.

(3) The plan sends a message about the use of alcohol & deals with the moral hazard.

Finally, we believe that this plan sends a very bold message that heavy use of alcohol is something very negative and undesirable. It sends a clear signal from the government about the detrimental effects of alcohol use. We believe that government can influence its citizens in this way.

In addition, it would simply deal with the moral hazard that sometimes is prevalent in the behaviour of individuals. At the point when they are not yet addicted, this plan can act as an active deterrent for people to take up drinking, since they will know that the downside of this decision will be faced by themselves.

We think these two effects are likely to decrease the overall amount of alcoholics in the society. Why is that efficient? Well, less health care resources will have to used to cure alcohol-related disorders. Also alcohol has other negative externalities that would be prevented. This is definitely beneficial for society.

One of the government’s roles is to distribute the welfare fairly. It is the government’s burden to help every citizen who is in a disadvantageous position. Thus it would be only fair if people who get sick could get the treatment at hospital.

On the other hand we believe that if there is no possibility to help every person in disadvantage, some requirements should be put. We believe there is a crucial difference between a person who is sick with flu getting his treatment in hospital and an alcoholic getting his kidney transplant. And we believe that people should be judged on their merits when the circumstances require so.

The argument is divided in two parts. First we prove why judging upon merit is fair in some cases, secondly we take a look on the nature of alcoholism and what is the proportion of individual’s fault in becoming one.

(1) Judgment upon merit

Justice is an ambiguous concept and debates about what is “fair” seem to never end. One of the definitions one could give to fairness is that all people should be given an equal right. However, in some cases there is no possibility to do so. Imagine a situation when we have one liver and two patients applying for a transplant. One of them is 50 years old and has been a heavy drinker for 20 years, which caused his liver disease, the other one is a young healthy man who has been doing sports all his lifetime and is concerned about his health condition, but got the liver disease because of bad genes. If we think in terms of fairness in this situation we have to provide them with an equal right for this liver. We cannot cut it in halves, thus the best “fair” decision we could make is to provide them with equal chances of getting the liver, i.e. to flip a coin. Although this is just, it is arguable whether the best outcome has been achieved.

First we see that a young healthy man has more chances to survive after the operation, which is brought in details in our first argument. Secondly, we believe that it was mostly the fault of alcoholic himself in getting the liver disease, thus it could have been prevented if he had been more concerned about his health. This leads us to the concept of judgment upon merit, thus taking into consideration the fault of a person in getting to the disadvantageous situation he is now.

There is a fundamental difference between getting flu and being treated from that and getting a liver disease because of alcoholism. In the case, a patient’s fault is negligible. For most it is his decision not to wear a scarf, otherwise it is mostly bad luck. In the second case it is mostly a decision of an individual to drink heavily and thus getting the liver disease. We believe that since the resources for treatment are scarce, it is fair to treat in the first place those who got the disease because of bad luck or bad genes, denying them who were responsible themselves in getting the disease.

People know that if they drink they get the liver disease, thus they are aware of these consequences when they make the decision to drink. In this case the disease is preventable, while in the case with bad genes it is unpreventable. If a person likes fast driving he is taking the responsibility for the possible consequences of his actions. Insurance companies deny fixing a car after a driving accident caused by the driver. Government in some cases could deny in providing the treatment for free after an accident which was caused by speeding. This is done because these people break the duty of care, break their responsibilities and take actions being aware of all the harmful consequences.

Moreover, if the government gives liver transplants to alcoholics it takes away it from other people. The government could try to distribute welfare in such a way that all citizens achieve the same satisfaction, thus all in need of treatment get the treatment. But it will sufficiently harm other people, since the government will end up in wasting scarce resources on people who don’t maximize their utility from these resources, people who waste their liver on heavy drinking.

But there is also another approach. The government tries to equalize endowments given to people at the initial stage, and then it is up to individual’s decision how to maximize utility from that. In such a case an alcoholic initially has a healthy liver and could prevent his disease, but a person with bad genes initially has an unhealthy liver and his disease is unpreventable, thus their endowments are not equal. It is the duty of government to equalize their states by giving a liver transplant to the person with bad genes, thus giving him a priority over the alcoholic.

One could say that being first in the waiting list is the fair criteria. However, we argue about whether to put heavy drinkers on this list at all. By putting them on the list, resources are taken away from other patients, thus the distribution occurs at the moment when it is decided whether to put a patient on the list. In the United States there are about 17,000 people waiting on the list, and the median time for waiting in 2006 was 321 days.[[http://www.livermd.org/waiting.html]] This illustrates the scarcity of the resource and makes the question of who should be given the liver inevitable.

(2) How the choice of becoming an alcoholic is made?

Some might argue that if we judge upon merit, we consider that all alcoholics have made the decision to become one only by themselves, thus no external factor was involved. Now we will try to get to the nature of alcoholism and identify any mechanisms how people become alcoholics.

First people are most likely to drink for fun. It is a clear situation of free choice and no external factors are involved. Then there are people who drink to support community around them: friends, relatives, colleagues etc. While in this case there is an external factor involved to some degree, we believe it is still not worth arguing that the decision is mostly a matter of the individual.

The next group of reasons for drinking we see is external community (bad neighborhood, alcoholic families etc.) and moral trauma or depression. In the first case while the external factors could put a significant pressure on the individual, so he starts drinking, it is still his free choice. To make an analogy: there is no such justification for committing a crime as pressure from external community. Also bad neighborhood of a convicted person is not a justification and by no means could reduce the punishment, since committing the crime was still a free choice decision. We believe that the same mechanism is applicable here. In the second case, people could seek for a fast solution in alcohol after they were exposed to a serious moral trauma. The proportion of individual’s decision is still pretty high, because, first of all, drinking is not the only solution and there are other means of dealing with depression; secondly, after the time has passed and the trauma has become less harmful, a person could abandon drinking.

We consider a significant influence of addiction to alcohol. To deal with it there are certain programs, such as Anonymous Alcoholics, which have proven to be pretty successful ones. So, even if a person has become addicted to alcohol, he could still cure from this addiction and prevent the liver disease from happening.

To sum up, we believe that when resources are scarce, it is acceptable to distribute them fairly upon merit, which allows punishing alcoholics for not taking care of their liver and giving priority to those who have the disease because of external factors. We see the decision to drink as a free decision made by an individual after a certain cost-benefit analysis, thus he is the one to take responsibility of all the consequences. Even if a person has become alcoholic due to external factors, he could still get rid of his addiction, thus preventing the liver disease. For all these reasons, we are proud of proposing the plan.

In this argument we will respond to some of the criticism as well as offer an additional mechanism through which our plan ensures efficient allocation of liver transplants.

Let’s start with our response to their rebuttal:

(a)

The opposition accused us of being brutal utility-maximizers. We believe that this disagreement is a semantic one. We never said that our definition of utility includes only base pleasures like sex, food etc. We simply stated that, given that we know what we want, we should strive to maximize it. These aims obviously can also include protecting citizens. We already aknowledged the problems with agreeing on what these desirable ends should be and presented reasons why saving lives should be important. There is no real disagreement here.

The opposition agrees with us that protecting lives of citizens is an end we should strive for. We believe that then they should agree with our plan. After all, the transplants are scarce. If a liver is given to an alcoholic, another person in the queue dies and maybe also alcoholic dies. If liver is given to someone else, that person lives and alcoholic dies. There is simply is no way of saving everyone with the available technology and current rates of transplant donation (more about that later), so government has to make a painful choices about the most efficient distribution of livers.

(b)

The opposition noted that the study we quoted finds that 38% of alcoholics use alcohol after transplantation and also provided some other statistics. We agree that there are studies with different findings regarding relapse of alcoholism. That is not surprising. The most important point is that there still is an important proportion of alcoholics who start drinking after the transplantation. Even if it is one person in ten, it is still a lot. We have shown how consumption of alcohol can often lead to lethal consequences after the operation.

Why is that bad? Because even if the number of alcoholics who start drinking is not overwhelming, it still means deprived opportunity to live for people who have made the right choices in their life. Meanwhile, the recipients of the liver squander their opportunity as well. We find this absolutely unacceptable.

(c)

The example of obese people was not used appropriately. There is a far stronger causal link between being an alcoholic and failed transplantation/recovery process than between being fat and failed transplantation/recovery process. If our aim is to distribute as efficiently and justly as possible, this distinction is very important.

(d)

We never that all people are perfectly rational and always take availability of transplants into account when going on with drinking. However, it is clear that our plan sends a clear negative message about the use of alcohol. Even if people do not care about transplants, their desire to conform socially means that the costs of drinking will go up. Attitude of their fellow citizens will make them understand that drinking is a very bad decision.

Finally, our fourth reason why our plan achieves distributional efficiency:

(4) It will increase the level of organ donation

Both sides in this debate agree that is unfortunate that we have so few livers that can be used for transplantation. Currently, very few people decide to donate their livers – a pitiful state of affairs. It does not have to be that way.

There are many reasons why people do not decide to give their organs for transplantation. We believe that one of the important factors (although not necessarily the most important one) is the recepient of the transplant.

People like helping others who share their genes, worldview, ethnicity, nationality and other things. This is a basic aspect of group psychology. Some people think it is unfortunate; however, that is the way human beings are wired up. According to the United Network for Organ Sharing, most living organ donors are family members of the recipient [[http://www.unos.org/news/newsDetail.asp?id=163]].

We believe that many potential donors are not agreeing to give away their liver precisely because it can received by a person the donor is not fond of. It is no surprise that there are many people who dislike alcoholics, think it is their own fault and would not want to give away their organs to help them. This is particularly true when consenting to donate a liver – after all, heavy drinkers represent a big proportion of the current recipients of livers.

If people know that their livers will be received by people who are not alcoholics, the level of donations is likely to go up.

Why is that efficient? Well, because it will help us to solve the disgraceful mismatch between people who have organs and can give them away with little cost (for instance, after death) and people who desparately need these organs to stay alive. Of course, alcoholics as a group will be significantly worse off; however, we are ready to accept this if it helps us to save the lives of all other people.

We quote “we are talking lives here”. Yes, we are, but unlike the opposition we believe that there are some things more general, not only tons of insignificant facts that don’t contribute to the debate. With all due respect to the opposition we believe that the opposition’s argumentation was weak and in the summary, we will try to prove why giving 1st chance to people is more important than giving 2nd chance to those who destroyed their life because of their past lifestyle.

The opposition has all the time been wining that they “value lives of people above everything”. Yes, we too. The opposition should understand that it is impossible at the moment to save everybody. If you save an alcoholic, because a young sporty guy could wait, you could get the situation where the young guy is not sporty anymore, since his disease progressed to the extent that a transplant won’t help him. The alcoholic lives while the young man dies. The opposition thinks that it is fair, we don’t.

The point is that even if at the moment a young guy could wait, no one is sure whether he will get his liver, since the number of organs available fluctuates all the time. Look at this story. [[http://www.guardian.co.uk/society/2009/sep/13/organ-donation-transplant-waiting-list]] Initially everybody thought that it will take him only 3 months of waiting, since in his blood group the donation rate was high. Unfortunately, the rates of donations have unexpectedly dropped, so now after 7 months no one is sure whether he will get his organ. We propose to give first of all organs to non-alcoholics and then see if we could treat alcoholics. This is both efficient and fair.

In our summary, first of, we will clarify the misunderstandings about our model and explain why the Status Quo is inefficient, afterwards, we will argue (1) whether alcoholics were responsible for their actions, (2) how efficient is it to give organs to alcoholics and, in the end, (3) is the government the one to decide.

First, let’s clarify the plan and model. It is no doubt that the liver transplants are scarce resource, which requires a different plan than the Status Quo, since more than 2,000 of people are dying while waiting for their liver each year in the US alone [[http://www.ustransplant.org/csr/current/fastfacts/datatour.aspx]].

The opposition brought up a point that our plan is arbitrary because we do not include smokers and drug addicts, but again we have to clarify that under the Status Quo doctors have the right to deny liver transplants for people, for example with Hepatitis B, so that they make sure that the chances of survival are higher. And even if it wouldn’t be under the plan, the statistics shows that alcoholics are significantly better represented in the waiting list comparing to people with obesity. In the end, the opposition didn’t give us any reference on how fat people or smokers get the liver disease. We assume that it is because there is no such mechanism.

The opposition argues how hard is it to determine who is/was an alcoholic. Even though we have to repeat ourselves, there are various measures how to do it – social stability, employment records, psychological and physical tests which can clearly provide data about the history of the individual.


(1) Are alcoholics responsible for their drinking problems?

As the key group of this debate is alcoholics, once and for all we have to clarify how responsible they are. The burden of proof for the government was to provide evidence that alcoholism was because of individual’s lifestyle and even if there were any external factors they could have been overcome.

First, as opposition didn’t refute our point in the argument of fairness, we can surely state that the significant amount of alcoholics started to use alcohol because of their free-will, and doesn’t matter whether they started doing it at age of 14 or 41, because the government did all the preventive functions: educating in schools, advertisement campaigns etc. Meanwhile we don’t deny that it is the government’s role to help them as much as possible to get rid of their addiction. And the government does it, take a look at Anonymous Alcoholics. Speaking about the external factors, as the opposition didn’t find it enough important to rebut, we believe that none of the surroundings could be a sufficient reason to be an excuse for being alcoholic, because it was both free choice and it is not enough justifiable as provided in the analogy of committing a crime because of a bad suburb. Similarly with genes, a person who is sick should seek for help from AA before the problem gets too serious. Anyway, as we provided in our reference, there is even no clear link proven between genetics and alcoholism.

The opposition argued that people don’t think prior the problem occurs. We don’t think that it somehow could decrease the responsibility of alcoholics because similarly you don’t get a lower sentence just because you didn’t know that killing 10 people will end with the imprisonment. We believe that there is enough information provided about the bad consequences of alcohol. After all, on each bottle of alcohol there is written with bold letters: “The usage of alcohol damages your health”.

Because of all these reasons, we believe alcoholism was a fault of these individuals and even if there was an influence from external reasons, it could have been prevented if a person wanted to.

(2) Is it efficient to give livers to alcoholics?

Even if we know that alcoholism was a fault of these individuals, would it impact the results of surgery and how likely a person would stop drinking after the surgery?

Chances of survival. Both sides agreed that if a person was an alcoholic, it decreases the chance of successful surgery. In the doubtful statistics the opposition has found and to which it gave a failed hyperlink, there was written that alcoholics have 5% less chances of surviving. Even if it is only 5%, on the proposition side, we believe that it is enough to give livers to non-alcoholics. Even if the opposition argues that this percentage is not enough significant, we have to take into consideration how the liver is used afterwards. The data shows that 38% of alcoholics who had liver transplantation started using alcohol. Even if there were only 1 in 10 people starting to use alcohol again, it is clearly too many. We on the government side believe that each life is valuable, but if there is a better chance of allocating the resource, so that it could save 5% of patients more, we go for it. At least, while there 2,000 people dying each year while being on the waiting list.

Assumption that those who will drink afterwards, most probably, will drink not as much to damage the liver again, we find silly. You don’t have to be a PhD in medicine to know that it will damage the liver anyway. Especially, if there is a high probability that the liver might not suit the person, alcohol will definitely increase the chance of failure. Also, we pointed out that drinking alcohol after the operation not only damages the liver, but has a harmful effect on the immune system of the body, which is crucial for a successful operation.

On the point about the evaluation of patients. We don’t buy that 6 month period of sobriety anyhow could decrease the blame of destroying the liver. What we are arguing is not for how long a person was sober but what was the reason to get the liver failure.

To sum up, we believe that it is by no means more efficient to give a liver to a person who has a higher possibility of survival, and even if under this plan we undermine any rights of alcoholics, it is very important to use the scarce resource in the best way possible taking into account even 5% difference.

(3) Is it justifiable for the government to prevent alcoholics from entering the line?

If we have clarified how alcoholics are responsible for their actions and how inefficient it would be to give transplants to them, is it still justifiable for the government to choose what’s the best for the whole society if clearly one group gets worse off?

We are very glad that the opposition brought up the point of who should be given a liver – is a 2nd chance for alcoholic better than a 1st chance for a person with an inherit decease? We do agree that lives should be treated equally if everybody had the same opportunity initially. But we believe it is fairer to give a chance for a person that didn’t have any opportunity before and didn’t damage his own health on purpose. Thus, it is fair to give livers to non-alcoholics.

The opposition believes it is unethical that somebody has to prove they deserve a transplant. On the government’s side we believe that it is ethical to save as many lives as possible and if the resource is scarce, we save those who have a higher possibility of survival. We don’t think that patients have to prove anything and nowhere in our plan or arguments we stated it. But we believe that each and every person has to be suitable for the surgery. However, we see that already under the Status Quo in California, which was given as a counter-plan from the opposition, doctors evaluate candidates in some cases based on their socio-economic group. We believe that if it is allowed, there is nothing wrong to evaluate based on the past decisions made.

Besides these three clash points we believe this plan introduces several benefits that were never really tackled.

The plan will send a clear message that alcoholism is inherently bad and will increase the costs of using it, which is desirable for any government. First it shows that the government doesn’t like alcoholics. Secondly, it once again reminds alcoholics about problems they could possibly have in the future. Thirdly, it deals with the issues of moral hazard alcoholics could have under the status quo.

Also, we believe that organ donations will increase. Even if the majority of people give their livers because of other reasons, one saved life is better than nothing. Such plan could increase the number of livers donated, because a person donating his liver will be sure that it is going to be received by an unlucky patient really in need, not an alcoholic that had been drinking for decades ruining his own organism. In any case, there is no reason that this plan will decrease the number of donors, so in that sense it could only bring benefits.

And the last, but not the least: doctors. As provided in the evidence in the USA and the UK doctors already have to decide which surgery would be too expensive or too unlikely to succeed. Our plan would only decrease the hard times for doctors as it would ease their decision upon preventing alcoholics from having a surgery.

Overall, we think that denying livers to alcoholics and giving them to those with bad luck is both efficient and fair. Even if it is only by 5% more efficient, we go for it. No doubts it is fair, since alcoholics are responsible themselves for their harmed livers. Moreover, this plan also brings some additional good effects. For both these reasons we beg you to propose the motion.

Already under the status quo doctors carry out an analysis before they make a decision whether to try an operation or not. There are cases when patients are hopeless and an operation won’t help them anyway. By denying them doctors save valuable transplants for other patients that are more likely to succeed with their operation. The opposition today is stating that the need-based criteria is the only one in deciding who to give a transplant. Well, no. There are other factors included in the process of evaluation. Let’s take a look at the system implemented in California to which the opposition has referred in their counter-model and see what are these criteria.

First it states that liver transplants are given to those patients that obtain maximum benefit from the procedure. Thus, it already implies the utilitarian approach. Then there is a list of diseases that qualify for having a transplant. There is also a part called “Contradictions to Transplant” where it is written in which cases doctors absolutely deny patients in having a transplant. This includes usually diseases or processes that significantly decrease the chances of a successful operation. And, among others, it includes “Active alcohol or substance abuse”. There are also “Factors that increase the risk of liver transplantation”, and these include “Advanced age”, “Chronic hepatitis B”, “Severe malnutrition” etc. It is not necessary that an operation will definitely be unsuccessful if a patient qualifies in one of these groups, but these factors decrease the chances of success and increase the costs of the operation. Doctors have a right to deny referring to these criteria to save valuable transplants for other patients and to save money, because operations to other patients will be cheaper. Thus, it implies the utilitarian approach.

There is a set of criteria used specifically to evaluate alcoholics. A patient with alcoholic cirrhosis will undergo a special scrutiny. The idea is to search for indicators for continued sobriety following the operation. And the criteria used are previous social stability, employment record and psychiatric status. This is a case of direct evaluation of patients in the counter-model our opposition has brought up. [[http://www.cpmc.org/advanced/liver/patients/topics/transplant.html]] We see that this model allows direct discrimination based on social status and employment, and this proves that necessity is not the only criteria used. In fact, such questions as “What’s the point of giving this man a new liver when he’s an alcohol addict who will probably relapse?” are already asked. And they are asked by the group of doctors including surgeons, psychiatrists, social workers, dietitians.

Referring to the Hippocratic Oath and other ethical guidelines we see that our plan simplifies lives of doctors, and takes away the burden of deciding and guilt of denying from them. Doctors evaluate patients even now, and the doctor facing a case of alcoholic cirrhosis should make a difficult ethical decision. On the one hand he has to help as many people as he could, but on the other if he helps this alcoholic, who is guilty in his disease himself, he is taking away chances of helping others. Other patients will have to wait for a new transplant, and there is a possibility that they die before they get a new organ. In the United Kingdom the burden of the decision whether to give a patient a liver is also lying on doctors. They have some guidelines and they are much wider than to give an organ to patient who needs it the most. [[http://www.uktransplant.org.uk/ukt/about_transplants/organ_allocation/liver/national_protocols_and_guidelines/protocols_and_guidelines/adults.jsp]] We see it only as a benefit of our model if we take away the burden and the guilt of denying from doctors and pass it in the form of legislation.

To sum up, we see that under the status quo doctors use several criteria in deciding who to give a new organ, not only the necessity. If it is allowed to use socio-economic status in this process, we see nothing bad in using the past behavior as a criteria. Our plan doesn’t contradict the general ethic guidelines used by doctors, but it takes away the burden of difficult decision making process from them and passes it on the legislation in the case of alcoholics. And the state has such a right, since organ transplants are treated as a national resource in most of the states. [[http://www.uktransplant.org.uk/ukt/about_transplants/organ_allocation/liver/national_protocols_and_guidelines/protocols_and_guidelines/adults.jsp]]

In the beginning we would like to mention that according to your lovely counter-plan (the procedure used in the state of California), Hepatitis B could be the reason to deny a liver transplant. [[http://www.cpmc.org/advanced/liver/patients/topics/transplant.html]]

We believe that giving a person a second chance to live is great, but giving him the first is even better. We would like to give priority to those that never had a chance to live fully with a healthy liver, rather than to those that had it initially, but wasted their organ behaving irresponsibly. If we had enough transplants for all patients, we would be happy to give them to everybody in need. Unfortunately, transplants are a very scarce resource. We could give first a transplant to a person who is more in need, but there is a substantial risk that the next person will die before he gets his transplant.

Returning to the case of an old man and a young sportiest. Imagine that an old alcoholic needs a transplant more urgently. According to the opposition he should be given a transplant, but there is a high risk that the operation will fail because he has other diseases, malnutrition, advanced age, which are all criteria used already by the commission to decide whether to put a patient on the waiting list. Moreover, there is quite a high risk of relapse. According to the statistics we have given before there were cases of alcoholic relapse in the first three months. Also 38% of drinking patients after an operation is a quiet high percentage we believe, since it shows only cases during the follow-up procedures. It should be not a surprise that constant control deters previous alcoholics after the operation. Unfortunately, no statistics could tell us what the rates after the follow-up period finishes are, but we could reasonably guess that they could be much higher. [[http://psy.psychiatryonline.org/cgi/content/full/42/1/55#SEC1]]

So, we give a transplant to an old alcoholic, because we believe that a young guy could wait for the next liver. Unfortunately, rates of donations have decreased, and he dies before he gets a new organ or his disease progresses so much that a transplant cannot help him anymore. We have saved an old person who could live for 3-5 years more if he doesn’t relapse, but we have sacrificed a person who could have lived for a longer period following an operation or even the whole normal life. Moreover, we have saved a person who was guilty himself in his disease, but sacrificed the one who just had a bad luck. We believe that this is neither an efficient or fair outcome.

Concerning the complexity of determining the cause for a liver failure, we challenge the opposition’s idea of correlation. When there is a strong correlation between A and B, that most likely means that A causes B. If the mechanism how A causes B is found out and proved then this is called not a correlation, but a causation. The mechanism how alcoholism causes a liver failure is definitely not new and could be called a causation rather than a correlation. [[http://www.liverfoundation.org/education/info/alcohol/]] Otherwise, there wouldn’t even be a term “Alcoholic liver disease.” Moreover, alcoholism is proved to be the most popular reason for a liver failure. [[http://www.britishlivertrust.org.uk/home/the-liver/liver-transplantation/a-history-of-liver-transplantation-and-current-statistics.aspx]] Such statistics shows us that there are techniques and criteria to establish the cases of alcoholism and that alcoholism is a reason number one for liver diseases.

We haven’t heard about such strong correlation between overeating and a liver disease. We would be grateful if the opposition tells us something about it.

Also even if we believe that in some cases alcoholism could be partially caused by irresponsible parents or genetic predisposition, we say that it was still the choice of an individual to start drinking. First in this case the term correlation is definitely a better one, because it has still not been proven that alcoholism could be caused by genetic predisposition. There is some empirical data, but additional research in this field should be made to reveal mechanisms and to call it being true. [[http://alcoholism.about.com/od/genetics/Genetics_of_Alcoholism.htm]] Even if this was true, if a person understands that he has a genetic predisposition towards alcoholism and catches himself on a though that he is becoming an alcoholic, he could sign to Anonymous Alcoholics and try to cure his predisposition. It was still his decision to start drinking and not to cure his addiction when it developed. That is why it is mostly him to blame for the disease. However, in the case of some other liver disease cases it was mostly bad luck, thus the person is less to blame.

We have read an article at BBC News about a young guy that died because he was refused in liver transplant. We say that it is sad. But this precedent has sent a bold message that alcoholism is something unacceptable in our society and it is something that could undermine it. Even if a person doesn’t think in a manner “Ok, I will drink, but then receive a transplant”, it still sends a message that alcoholism is inherently bad.

Also if we speak about the level of guilt in receiving Hepatitis because of drinking from the same bottle and alcoholism, we see that the level of guilt in a liver failure as a consequence of alcoholism is much higher. Although the decision to drink from the same bottle was also made by an individual, it was just a one decision. However, developing alcoholism is a set of many decisions made by an individual. A person can’t become an alcoholic because he tried a beer once. He has to drink constantly for a substantial period of time in order to cause a liver failure, thus it is a consequence of many decisions made by an individual. We believe that in the case of one decision made that led to the liver failure the level of guilt is lower than in the case of many decisions. Decisions to start drinking, many decisions to continue drinking from the bottles labeled “Alcohol is bad for your health!” and decisions not to treat the addiction are all parts of this huge set that represents the route chosen by the individual. Thus the degree of guilt in this case is very high.

Overall, we believe that we should give a chance to live first to those that never had it. Secondly, we see evidence that alcoholism is a reason for a liver failure in most cases, and we have a set of criteria to determine it. Then even if person has a genetic predisposition towards alcohol, it was still his decision to start drinking. Lastly, the decision to drink from the same bottle that led to Hepatitis was a decision taken once, but the decision to become an alcoholic that led to a failed liver was a set of many decisions made by an individual. Thus the degree of guilt in the first case is lower than in the former.

Well, there is not too much to answer. Everything pretty much was already said before. But, anyway, few points of clarification.

First what are the sources of the statistics of 85% and 90% survival rates? If the opposition is talking about their very first point then we feel a little bit betrayed, since they kindly asked us to ignore this point claiming that they cannot delete it. If you give such statistics reference it. Otherwise it seems counter intuitive. Moreover, if we take a look at their quote when these rates appeared, we could see just a clear flaw there. Quoting: “However for those patients that do receive an organ transplant, nearly 90% percent live for more than a year and 80% lives for more than 4 years. And even in case of alcoholic patients the survival rate for more than 10 years is 85% – exhibiting small difference from that of normal patients.” How come 80% of all patients live for more than 4 years, but 85% of alcoholics live for more than 10 years. There is a clear mistake. Unfortunately, the link referencing this source doesn’t work.

Secondly, we deny livers to alcoholics not only because they “brought the disease upon themselves”, but also because giving it to a non-alcoholic is more efficient. Even if we believe in the difference of 5% it is good enough to make a decision who gets the scarce resource. So, we will deny livers to alcoholics because of efficiency and fairness. This is also the answer to the point about relapse.

Once again about the Hippocratic Oath. By the way the Hippocratic Oath claims “never do harm to anyone”, which is nothing to do with the discrimination based on the previous lifestyle. The discrimination point is the product of ethical guidelines doctors have in the UK, which were developed as all the laws and could be changed. Anyway, we believe that no breaking of the Oath or any other ethical guideline is involved, since doctors allocate the scarce resource in the most efficient manner, and if non-alcoholics survive in the 90% of cases, while alcoholics only in the 85%, it is the best of doctors to cure non-alcoholics first. They already make such decisions and deny to those whose treatment possibility is doubtful, so they already discriminate. And as we pointed out in California (which laws the opposition brought as a counter-plan) it is allowed to discriminate based on socio-economic status. We see no problem then to discriminate also based on the past experience. Anyway, the doctors won’t break the Oath, because the law will prohibit them from giving a transplant to an alcoholic, since the government believes that people have to pay for their mistakes. In such a way this burden is completely removed.

We didn’t get the first paragraph. Sorry. The only thing we got from it is “when doctors don’t have the right to make a choice in the first place…”. Well, just in the previous point you told yourselves: “However, the reality is that making the final decision on whether or not the patient will be able to survive and how much the “blame” is to be placed on is fundamentally made by the doctors. It is a burden that they cannot simply be dismissed from.” Please, be consistent with your speeches. Otherwise, it is hard to understand.

Yeah, we agree we are talking lives here. However, on the side of the government we are weighting this thing up to achieve the best result, while the opposition simply is shouting about how much they value lives. Look at this data. [[http://www.ustransplant.org/csr/current/fastfacts/datatour.aspx]] It shows that there is a great mismatch between the number of livers available and the number of patients in need. It also shows that more than 2,000 people die every year while in the waiting list. On the side of the proposition we believe that these 2,000 people should be alcoholics, since they are the ones to blame for their disease, while non-alcoholics that were unlucky to get the disease should get their livers first. It will be more efficient (even in the doubtful case of 85% versus 90%) and fair at the same time.

Once again about alcoholism causing liver disease. Come on. We gave you references. Here you are once again. It is clearly written there “Alcohol was the highest cause for a liver transplant with 652 transplants (following a standard six months abstinence period).” [[http://www.britishlivertrust.org.uk/home/the-liver/liver-transplantation/a-history-of-liver-transplantation-and-current-statistics.aspx]] And here all the mechanisms are explained. [[http://www.liverfoundation.org/education/info/alcohol/]] However, when we asked to give references on effects of cigarettes or fatty food on the liver disease, we got none. It is because the causation there is much weaker. Please, when you claim anything scientific, which couldn’t be described by simple logics, make references. Otherwise, such quotes about alcohol causing the liver disease as “nor is it a much more detrimental factor than other factors”, don’t sound really valid.

And finally, about the mistakes made over time and one mistake versus thousands of them. Your favorite California medical center for liver transplantation already analyses the psyche of their patients to make sure that they don’t relapse. We clearly described the mechanics how we see such a decision-making process. In the case of Hepatitis because of one sexual act when one decision was made, and in the case of alcoholism when plenty of decisions to drink and not to stop were made. Yes, we see the fault of the patient higher in the second case. You didn’t provide any substantial refutation, except of saying that we will be “considering the socio-economic background and the past psyche of the patients before deciding on whether they would allow doctors to perform liver transplants”. Yes, we could to that. Under you sweet counter-plan it is already done. I would suggest you reading what is written in your counter-plan before proposing it.